Dialysis Vascular Access Coverage, Coding and Reimbursement Overview — Physician / Hospital / ASC

2016 Edition† — All Reimbursement Amounts are Listed at National Unadjusted Medicare Rates and Do Not Include the 2% Sequestration Reduction

PHYSICIAN OVERVIEW

Physician rates effective January 1, 2016 through December 31, 2016.

COVERAGE Medicare Medicaid Commercial Insurance

A/B MAC/Carrier Local Coverage Determination/National Coverage Determination State Policies Plan Design, Medical Policies, Patient Eligibility

CREATION A

CODING

REIMBURSEMENT B

Vascular Access

CPT Code

Professional Technical or or Facility Non-Facility

®

Procedure Arteriovenous anastomosis, open; by upper arm cephalic vein transposition Arteriovenous anastomosis, open; by upper arm basilic vein transposition Arteriovenous anastomosis, open; by forearm vein transposition Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure) Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft)

36818 36819 36820 36821

$734 $776 $774 $703

— — — —

36825

$848

—

36830

$707

—

36005 75820 75822 93971

$50 $35 $53 $23

$330 $81 $86 $100

ImagingC, D Injection procedure for extremity venography (including introduction of needle or intracatheter) Venography, extremity, unilateral, radiological S&I Venography, extremity, bilateral, radiological S&I Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study

MAINTENANCE A

CODING

REIMBURSEMENT B

Procedure Revisions Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; venous Introduction of needle and / or catheter, arteriovenous shunt created for dialysis (graft / fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection(s) of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava) additional access for therapeutic intervention Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome) Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis) Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological S&I and including all angioplasty within the same vessel, when performed; inital artery each additional artery Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological S&I and including angioplasty within the same vessel, when performed; initial vein each additional vein Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty

Imaging

35475 35476

$349 $282

$1,591 $1,458

36147

$194

$856

+36148

$51

$267

36831

$654

—

36832

$802

—

36833

$860

—

36838

$1,212

—

36870

$313

$1,874

37236

$476

$4,202

+37237

$224

$2,512

37238

$330

$4,285

+37239

$157

$2,073

37224

$482

$3,914

75791

$88

$241

75962

$27

$115

75978

$27

$113

90940 93990

$0 $25

$0 $140

C, D

Angiography, arteriovenous shunt (eg, dialysis patient fistula / graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological S&I Transluminal balloon angioplasty, peripheral artery other than renal, or other visceral artery, iliac or lower extremity, radiological S&I Transluminal balloon angioplasty, venous (eg subclavian stenosis), radiological S&I

Other Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)

A. Abbreviated CPT® code descriptions. See CPT® codebook for complete descriptions. B. Conversion factor used for this overview is $35.8043, per 2016 National Physician Fee Schedule Relative Value File, January release, dated January 5, 2016. C. For imaging services (excluding screening and diagnostic mammograms), the DRA of 2005 caps the physician technical component rate at the payment level established for the OPPS fee schedule. D. Certain imaging and diagnostic cardiovascular services are subject to Multiple Procedure Payment Reduction rules-refer to CMS-1631-FC for affected services.

HOSPITAL (FACILITY) INPATIENT OVERVIEW

Hospital Inpatient rates effective October 1, 2015 through September 30, 2016.

COVERAGE Medicare

A/B MAC/Fiscal Intermediary Local Coverage Determination/National Coverage Determination

Medicaid

State Policies

Commercial Insurance

CREATION

Plan Design, Medical Policies, Patient Eligibility

REIMBURSEMENT

A

MS-DRG ICD-10-PCS: Bypass; Upper Artery; Open; Tissue or Synthetic Substitute

252 253 254 264 673 674 675

MAINTENANCE A Bypass; Upper Artery; Open; Tissue or Synthetic Substitute Removal; Upper Artery; Open, Percutaneous, or Percutaneous Endoscopic; Tissue or Synthetic Substitute Extirpation; Upper Artery or Vein; Open, Percutaneous, or Percutaneous Endoscopic Repair; Upper Artery or Vein; Open, Percutaneous, or Percutaneous Endoscopic

B

Inpatient (IPPS) Relative Weight C

Rate D

3.2872 2.6028 1.7232 2.8080 3.3559 2.3148 1.5595

$19,415 $15,373 $10,177 $16,584 $19,820 $13,672 $9,211

REIMBURSEMENT 252 253 254 264 673 674 675

3.2872 2.6028 1.7232 2.8080 3.3559 2.3148 1.5595

$19,415 $15,373 $10,177 $16,584 $19,820 $13,672 $9,211

Dilation; Upper Artery; Open, Percutaneous, or Percutaneous Endoscopic; Drug-eluting Intraluminal Device, Intraluminal Device, or No Device Dilation; Upper Vein; Open, Percutaneous, or Percutaneous Endoscopic; Intraluminal Device or No Device Dilation; Upper Artery; Percutaneous or Percutaneous Endoscopic; Drug-eluting Intraluminal Device or Intraluminal Device Dilation; Upper Vein; Open, Percutaneous or Percutaneous Endoscopic; Intraluminal Device Bypass; Radial Artery; Open; Synthetic Substitute; Lower Arm Vein Removal; Upper Artery; Open, Percutaneous, or Percutaneous Endoscopic; Synthetic Substitute Revision; Upper Artery; Open, Percutaneous or Percutaneous Endoscopic; Synthetic Substitute Administration; Introduction; Peripheral Vein, Central Vein, Peripheral Artery, or Central Artery; Open or Percutaneous; Other Thrombolytic A. Abbreviated ICD-10-CM descriptions. See ICD-10-CM codebook for complete descriptions. Listed are common primary procedures. Code additional procedures in accordance to coding guidelines. B. MS-DRG assignment is determined by the patient ICD-10 diagnoses and procedure code(s). Listed are examples of possible MS-DRGs. Injury and trauma not listed. C. Hospital reimbursement varies significantly based on a number of variables. Relative weight is provided as a constant used in the calculation of individual hospital reimbursement. D. Rates per CMS-1632-F.

MS-DRG Descriptions 252 - Other vascular procedures with MCC 253 - Other vascular procedures with CC 254 - Other vascular procedures without CC/MCC 264 - Other circulatory system O.R. procedures 673 - Other kidney and urinary tract procedures with MCC 674 - Other kidney and urinary tract procedures with CC 675 - Other kidney and urinary tract procedures without CC / MCC

HOSPITAL (FACILITY) OUTPATIENT OVERVIEW

Hospital Outpatient rates effective January 1, 2016 through December 31, 2016.

COVERAGE Medicare

A/B MAC/Fiscal Intermediary Local Coverage Determination/National Coverage Determination

Medicaid

State Policies

Commercial Insurance

Plan Design, Medical Policies, Patient Eligibility

CODING

REIMBURSEMENT

HCPCS / CPT® Code

Outpatient (OPPS) APC SI A Rate B May be Required for Medicare Outpatient Claims

Device Code * Graft, vascular Stent, coated / covered, with delivery system

CREATION C

C1768 C1874

CODING

Procedure Arteriovenous anastomosis, open; by upper arm cephalic vein transposition Arteriovenous anastomosis, open; by upper arm basilic vein transposition Arteriovenous anastomosis, open; by forearm vein transposition Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure) Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft)

— —

N N

— —

REIMBURSEMENT

36818 36819 36820 36821

5182 5183 5182 5182

T T T T

$2,247 $3,795 $2,247 $2,247

36825

5183

T

$3,795

36830

5183

T

$3,795

36005 75820 75822

­­— 5525 5525

N Q2 Q2

$668 $668

93971

5532

S

$154

Imaging Injection procedure for extremity venography (including introduction of needle or intracatheter) Venography, extremity, unilateral, radiological S&I Venography, extremity, bilateral, radiological S&I Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study

MAINTENANCE

C

Procedure Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; venous Introduction of needle and / or catheter, arteriovenous shunt created for dialysis (graft / fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection(s) of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava) additional access for therapeutic intervention Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome) Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis) Transcatheter placement of an intravascular stent(s) (except lower extremity for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological S&I and including all angioplasty within the same vessel, when performed; initial artery each additional artery Transcatheter placement of an intravascular stent(s) open or percutaneous, including radiological S&I and including angioplasty within the same vessel, when performed; initial vein each additional vein Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty Imaging Angiography, arteriovenous shunt (eg, dialysis patient fistula / graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological S&I Transluminal balloon angioplasty, peripheral artery other than renal, or other visceral artery, iliac or lower extremity, radiological S&I Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological S&I Other Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)

CODING

—

REIMBURSEMENT

35475 35476

5191 5191

J1 J1

$4,592 $4,592

36147

5181

T

$863

+36148

—

N

—

36831

5182

T

$2,247

36832

5183

T

$3,795

36833

5183

T

$3,795

36838

5183

T

$3,795

36870

5191

J1

$4,592

37236

5192

J1

$9,542

+37237

—

N

—

37238

5192

J1

$9,542

+37239

—

N

—

37224

5191

J1

$4,592

75791

5525

Q2

$668

75962

—

N

—

75978

5182

Q2

$2,247

90940 93990

— 5531

N Q1

$92

—

A. Status Indicators: C-Inpatient Procedures; J1-Hospital Part B Services Paid Through a Comprehensive APC; N-ltems and Services Packaged into APC Rates; Q1-STV-Packaged Codes; Q2-T-Packaged Codes; Q3-Codes That May Be Paid Through a Composite APC; S-Procedure or Service, Not Discounted When Multiple; T-Procedure or Service, Multiple Procedure Reduction Applies. B. Rates per CMS-1633-FC. C. Abbreviated CPT® code descriptions. See CPT® codebook for complete descriptions. * Procedures that require the implantation of a device assigned to a device-intensive APC (Table 42) require a device HCPCS code and NCCI edits apply per CMS-1633-FC.

AMBULATORY SURGERY CENTER (ASC) OVERVIEW

ASC rates effective January 1, 2016 through December 31, 2016.

COVERAGE Medicare

A/B MAC/Carrier Local Coverage Determination/National Coverage Determination

Medicaid

State Policies

Commercial Insurance

CREATION

Plan Design, Medical Policies, Patient Eligibility

A

CODING

REIMBURSEMENT B

CPT Code

Rate

36818 36819 36820 36821

$1,257

36825

$2,122

36830

$2,122

36005 75820 75822

Packaged Packaged Packaged

93971

Non-covered

CODING

REIMBURSEMENT B

35475 35476

$1,315

36147

$482

®

Procedure Arteriovenous anastomosis, open; by upper arm cephalic vein transposition Arteriovenous anastomosis, open; by upper arm basilic vein transposition Arteriovenous anastomosis, open; by forearm vein transposition Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure) Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft)

Imaging

$2,122 $1,257 $1,257

D

Injection procedure for extremity venography (including introduction of needle or intracatheter) Venography, extremity, unilateral, radiological S&I Venography, extremity, bilateral, radiological S&I Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study

MAINTENANCE A Procedure Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; venous Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection(s) of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava) additional access for therapeutic intervention Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome) Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis) Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological S&I and including all angioplasty within the same vessel, when performed; initial artery each additional artery Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological S&I and including angioplasty within the same vessel, when performed; initial vein each additional vein Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty

Imaging

+36148

$1,244

Packaged

36831

$1,257

36832

$2,122

36833

$2,122

36838

Non-covered

36870

$2,288

37236

$5,984

+37237

Packaged

37238

$5,984

+37239

Packaged

37224

$2,288

75791

Packaged

75962

Packaged

75978 90940 93990

Packaged Non-covered Non-covered

C

Angiography, arteriovenous shunt (eg, dialysis patient fistula / graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological S&I Transluminal balloon angioplasty, peripheral artery other than renal, or other visceral artery, iliac or lower extremity, radiological S&I Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological S&I Hemodialysis access flow study to determine blood flow in grafts and AV fistulae by an indicator method Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)

A. Abbreviated CPT® code descriptions. See CPT® codebook for complete descriptions. B. Rates per CMS-1633-FC. C. Certain imaging and diagnostic cardiovascular services are subject to Multiple Procedure Payment Reduction rules-refer to CMS-1633-FC for affected services.

EXAMPLE CASES CASE 1: ACCESS CREATION – OUTPATIENT SURGICAL CREATION OF PTFE GRAFT FOR AV ACCESS HCPCS / CPT® Code A

Physician Hospital Outpatient Technical or Non-Facility Extension of Professional Practice or Facility APC SI B Rate

ASC

Rate

Procedure Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft)

36830

Case Total

—

$707

—

$707

5183

T

$3,795

$2,122

$3,795

$2,122

CASE 2: FISTULA REVISION – OUTPATIENT PTA AND STENT HCPCS / CPT® Code A

Physician Hospital Outpatient Technical or Non-Facility Extension of Professional Practice or Facility APC SI B Rate

ASC

Rate

Access Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft / fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection(s) of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)

36147

$428 (50%)

$97 (50%)

5181

T

Packaged

$241 (50%)

+36148

$267 (100%)

$51 (100%)

—

N

—

Packaged

Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological S&I and including angioplasty within the same vessel, when performed; initial vein

37238

$4,285 (100%)

$330 (100%)

$9,542 (100%)

$5,984 (100%)

Stent, coated / covered, with delivery system

C1874

additional access for therapeutic intervention

Procedure

Case Total

—

—

$4,980

$478

5192 J1 —

N

—

—

$9,542

$6,225

CASE 3: FISTULA REVISION – OUTPATIENT BALLOON THROMBECTOMY WITH PTA HCPCS / CPT® Code A

Physician Hospital Outpatient Technical or Non-Facility Extension of Professional Practice or Facility APC SI B Rate

ASC

Rate

Access Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft / fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection(s) of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)

36147

$428 (50%)

$97 (50%)

5181

Packaged

$241 (50%)

Transluminal balloon angioplasty, percutaneous; venous

35476

$729 (50%)

$141 (50%)

5191 J1 Packaged

$622 (50%)

Device code required for PTA

CXXXX

—

—

36870

$1,874 (100%)

$313 (100%)

75978

$113 + Pro Fee

$27

5182 Q2 Packaged Packaged

$3,144 + Pro Fees ($27)

$578

$4,592

T

Procedure

Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis)

—

N

5191 J1

—

Packaged

$4,592

$2,288 (100%)

Imaging Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological S&I

Case Total

$3,151

A. Review CPT® coding guidelines, modifiers, and NCCI edits for these codes. B. Status Indicators: C-Inpatient Procedures; J1-Hospital Part B Services Paid Through a Comprehensive APC; N-ltems and Services Packaged into APC Rates; Q1-STV-Packaged Codes; Q2-T-Packaged Codes; Q3-Codes That May Be Paid Through a Composite APC; S-Procedure or Service, Not Discounted When Multiple; T-Procedure or Service, Multiple Procedure Reduction Applies. * Procedures that require the implantation of a device assigned to a device-intensive APC (Table 42) require a device HCPCS code and NCCI edits apply per CMS-1633-FC.

TERMINOLOGY AND ACRONYMS A/B MAC: A/B Medicare Administrative Contractor. A Medicare contractor responsible for administration and adjudication of claims for hospital inpatient, hospital outpatient, physicians and ASC treatment settings. ABN: Advance Beneficiary Notice. A legal, written notice to a Medicare beneficiary from a physician or hospital informing the patient that the health service or item that the physician has prescribed is not or may not be a covered service under Medicare and that the patient will be responsible for payment if denied. Anesthesia Guidelines: The rules for coding and charging are complex. Variable circumstances can include duration, method of anesthesia / sedation, the physician or specialist administering services, and the site of service. Local Medicare policies and the AMA CPT® coding book, professional edition, should be consulted for questions regarding the proper coding and billing for anesthesia services. APC: Ambulatory Payment Classification. These are numeric classifications used by Medicare to reimburse services performed in a hospital outpatient setting. An APC will contain multiple HCPCS codes that are similar both clinically and in terms of resources used by the hospital. The APC rate is set prospectively by CMS based on historic claims data. APC Status Indicator: Alpha characters are used to designate the APC payment calculation method. For multiple APCs on a single claim with status indicator “T” the first APC will be paid at 100% and all others at 50%. For all APCs with Status Indicator “S” each APC will be paid at 100% without discounting. ASC: Ambulatory Surgery Center. When used by Medicare, this designation describes a legal licensing status establishing a site of service distinct from a physician’s office or hospital-based facility. Bundled: Certain supplies / procedures provided by a physician as described by CPT® / HCPCS codes may be included (“bundled”) with another service for reimbursement purposes. C-APC: Comprehensive Ambulatory Payment Classification. These APCs provide all-inclusive payments for certain procedures. This policy packages payment for all items and services typically packaged under the OPPS and also packages payment for other items and services that are not typically packaged under the OPPS. The single payment for a comprehensive APC excludes services that cannot be covered by Outpatient Department (OPD) services or cannot by statute be paid under the OPPS. Carrier / Part B: A Medicare contractor responsible for physician and ASC medical policies, adjudication of claims, and other administrative functions. CC: Complications and Comorbidities. Patient conditions utilized as two of several factors in MS-DRG groupers. CCI: Correct Coding Initiative. A listing of CPT® codes that are designated as comprehensive or component codes. If comprehensive and component codes are submitted on the same bill, only the comprehensive code will be paid unless a

CMS: Centers for Medicare & Medicaid Services. The federal agency that runs the Medicare program. CMS also works with the states to run the Medicaid program.

MCC: Major Complications and Comorbidities. Patient conditions utilized as two of several factors in MS‑DRG groupers. MCC are typically significant acute manifestations or advanced stages of chronic conditions that would result in higher resource utilization in the course of treatment.

CPT® Code: Current Procedural Terminology Code. These 5-digit numeric codes are the property of the American Medical Association and are used to describe physician services. Additionally, Medicare licenses these codes from the AMA and uses them to describe physician, hospital outpatient, ASC services, and other outpatient services.

MDC: Major Diagnostic Category. Individual MS-DRGs are grouped into mutually exclusive groups based on principal diagnosis. Each group (MDC) generally corresponds to a single organ system and is further organized into a medical or surgical section. A case is assigned to a surgical section MDC based on operating room procedure performed.

DRG: Diagnosis-Related Group. A numeric classification system used by Medicare and some commercial payers to reimburse for hospital inpatient services. The DRG is assigned by software that considers the ICD-10 procedure and diagnosis codes submitted on a claim.

MS-DRG: Medicare Severity Diagnosis-Related Group. A numeric classification system used by Medicare to reimburse for hospital inpatient services. The MS-DRG is assigned by the combination of ICD-10 procedure codes, diagnosis codes, and the presence or absence of MCC / CCs as derived from the medical record documentation. The MS-DRG system was designed to more accurately pay hospitals based on patient severity of illness.

modifier is submitted. Medicare uses these as NCCI (National Correct Coding Initiative) edits.

DME: Durable Medical Equipment. Certified supplies, prosthetics, equipment, etc. provided to patients in other than a hospital inpatient setting.

Modifier: A 2-digit alphanumeric code that is appended to a CPT® code for further specificity.

DMERC: Durable Medical Equipment Regional Contractor. Medicare contractor that adjudicates claims for DME providers.

NCD: National Coverage Determination. The written policies from Medicare that have a national jurisdiction. A NCD supersedes a LCD.

Facility / Non-Facility: For some physician procedures, the reimbursement is determined by the site of service. If the fee is designated as “facility,” the procedure is performed in a site of service other than a physician office. If the fee is designated as “non-facility,” the procedure is performed in a physician office.

Observation: Hospital outpatient services to monitor and assess a patient for determination of hospital admission. OPPS: Outpatient Prospective Payment System. Medicare per group (see “APC”) methodology for hospital outpatient services.

FI: Fiscal Intermediary / Part A. A Medicare contractor responsible for hospital inpatient and outpatient medical policies, adjudication of claims, and other administrative functions.

Outpatient: A patient admitted to a hospital to receive treatment but not admitted as an inpatient (see “Observation”). Packaged: Certain supplies / procedures provided by a facility as described by CPT® / HCPCS codes may be included (“packaged”) with another service for reimbursement purposes.

HCPCS: Healthcare Common Procedure Coding System. The name of a coding system established by Medicare to describe services and supplies. The base (Level I) codes are CPT® codes.

Prospective: A predetermined reimbursement rate, regardless of the cost of that service.

ICD-10: International Classification of Diseases. Alphanumeric clinical coding system for diagnoses and procedures. The combination of procedure and diagnosis codes determines DRG assignment for inpatient reimbursement.

Pro / Tech: Professional / Technical. For some diagnostic tests, the physician reimbursement is established in two components. The “professional” component is for the physician supervision, interpretation, and other personal service. The “technical” component is for the equipment, supplies, staff, and other costs related to the test.

ICD-10 procedure 7 character alphanumeric codes (e.g., 04V03DZ Restriction of Abdominal Aorta with Intraluminal Device, Percutaneous Approach) Abbrev: Px.

S&I: Supervision and Interpretation. This term is sometimes used to differentiate the imaging service (professional reading / interpretation) from other components of the procedure, such as introduction and placement of catheters.

ICD-10 diagnosis 3–7 alphanumeric codes (e.g., I71.4 Abdominal aortic aneurysm, without rupture) Abbrev: Dx. Inpatient: The status used to describe a patient who has been admitted to the hospital. Usually involves multi-day stay.

Unadjusted Rate: The prospective reimbursement rate before it is adjusted for local factors such as the wage index, graduate medical education, outlier cases, disproportionate share, and other factors. This is sometimes called the “national average” rate. All Medicare reimbursement will have local adjustment factors.

IPPS: Inpatient Prospective Payment System. Medicare per case (see “DRG” and “MS‑DRG”) methodology for hospital inpatient services. LCD: Local Coverage Determination. The written policies produced by Medicare contractors applicable to geographic areas. A CMS national policy (see “NCD”) supersedes a LCD.

RESOURCES Suggested Resources: Coding and reimbursement is complex, specific to case documentation and variable by geographic location. Always consult current physician, hospital and ASC resources.

1. Medicare Coverage Database. National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Baltimore, MD: Centers for Medicare and Medicaid Services -US Department of Health & Human Services. http://www.cms.gov/medicare-coverage-database/overviewand-quick-search.aspx . Updated December 15, 2015. Accessed January 15, 2016.

9. CY2016 Hospital Outpatient Prospective Payment System (OPPS) Final Rule. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Hospital-OutpatientRegulations-and-Notices-Items/CMS-1633-FC.html . Published November 13, 2015. Accessed January 15, 2016.

2. Society of Interventional Radiology. 2016 Interventional Radiology Coding Update. 22nd ed. Fairfax, VA: Society of Interventional Radiology; 2016.

10. CY2016 Ambulatory Surgical Center (ASC) Payment System Final Rule. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ASCPayment/ASC-Regulations-and-NoticesItems/CMS-1633-FC.html . Published November 13, 2015. Accessed January 15, 2016.

3. American Medical Association. CPT® 2016 Professional Edition. Chicago, IL: American Medical Association; 2015.

W. L. Gore & Associates, Inc. Flagstaff, AZ 86004 800.437.8181 928.779.2771 For additional product information, visit goremedical.com Products listed may not be available in all markets. CPT® is a trademark of American Medical Association. NAVIGATOR® is a trademark of Coding Strategies, Inc. GORE® and designs are trademarks of W. L. Gore & Associates. © 2005, 2006, 2008–2016 W. L. Gore & Associates, Inc.  AH0226-EN16  MARCH 2016

4. ICD-9-CM and ICD-10. Centers for Medicare and Medicaid Services Web site. http://cms.gov/ICD9ProviderDiagnosticCodes . Updated February 06, 2014. Accessed January 15, 2016. 5. Coding Strategies, Inc. 2016 Navigator® for Interventional Radiology/Procedures. Powder Springs, GA: Coding Strategies, Inc; 2015. 6. Coverage, Coding, and Reimbursement. W. L. Gore & Associates, Inc. Web site. http://www.goremedical.com/global/coding-andreimbursement-landing?locale=mpd_na . Accessed January 15, 2016. 7. CY2016 Physician Fee Schedule (PFS) Final Rule. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Federal-Regulation-NoticesItems/CMS-1631-FC.html . Published November 16, 2015. Accessed January 15, 2016. 8. FY 2016 Inpatient Prospective Payment System Final Rule. Centers for Medicare and Medicaid Services Website. http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-HomePage.html . Published August 17, 2015. Accessed January 15, 2016.

Disclaimer: The payment amounts listed in this guide are national averages. Actual payment will vary based on several factors including the site of the service, geographic location, patient population mix, and hospital teaching status. References to particular applications and procedures listed in this overview do not represent the appropriateness or market availability of any Gore medical product. The information contained in this overview is provided for general information purposes only and should NOT be relied on for submission purposes. Consult your professional resources and the patient’s insurer for situation-specific information. Physicians and hospitals are responsible for selecting and reporting the code(s) that most accurately describe the procedure(s) performed, the products used and the patient’s condition. The basis for accurate coding is clear and complete documentation in the medical record, precisely describing the procedures performed and products used.

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Providers should follow coding guidelines from the patient’s insurer and should also review the complete coding authorities (e.g., CPT®, HCPCS, ICD-10-CM) used by the insurer. The identification of a code in this overview should not be construed to guarantee coverage for a product or procedure or payment in any particular amount.